- Email: [email protected]
263: Prevalence of Methicillin Resistant Staphylococcus aureus In Out-of-Hospital Health Care Providers
Research Forum Abstracts Methods: A timeline representing a patient’s course through the ED was created. From this model patient flow was analyzed using Six Sigma methodology. Each step of the flow process was defined and analyzed for sources of delays and opportunities for improvement. Process changes were proposed and tested in the clinical area after educating the ED and house staff. The initiative was reviewed periodically at 30, 60 and 90 days to ensure sustainability. Results: Using Six Sigma methodologies we were able to decrease the time from admission order to the time of bed assignment from an average of 49 minutes (SD 69) to 28 minutes (SD 21). We also decreased the time from bed assignment to transport to the ward from a mean of 111 minutes (SD 63) to 66 minutes (SD 20). Conclusion: The objective nature of the Six Sigma methodology fosters successful implementation of ED process improvement. Identification of correctible causes of system problems allows for greater likelihood of sustainable performance improvement.
262
Quantification of Daily Surge Volume In the Emergency Department
Milzman DP, Soe-Lin H, Orr J, Elliot J/Georgetown U School of Medicine/ Georgetown WHC EM Residency, Washington, MD
Study Objective: Proposals to deal with surges in patient volume have ranged from disease-specific triage management protocols to disaster-specific medical response protocols. Attempts to conceptually qualify what constitutes a surge volume, and daily fluctuations in patient volume that do not overwhelm emergency department capacity, can be categorized as a daily surge. However, to date no studies have attempted to empirically quantify what volume of patients constitutes a true surge. The current study examines the effect of daily fluctuations in patient volume retrospectively over a three-year period. Methods: Using Azyxxi, the electronic medical records system developed by Smith and Feied (Microsoft, Redmond WA), a retrospective database analysis was conducted for all patients entering the emergency department of a 900-bed tertiary care level 1 trauma center with approximately 85,000 ED visits per year, over a threeyear period from 2005 to 2008. Age, sex, race, and disposition demographics were collected on a per day basis, as well as labs, x-rays, and CT scans ordered on that day. Over the 1095 days of collected data, patient subcohorts of low and high volume days were constructed based on either standard deviations below and above the mean, respectively. Percentage of tests ordered as well as disposition profiles between these groups were subsequently compared via two-sample Wilcoxon rank-sum (MannWhitney) using STATA SE 10.0 statistical software (StataCorp, College Station TX). Results: Over 1095 days of collected daily patient volume, the mean number of patients was 210 with a standard deviation of 40. Patients within one standard deviation of the mean, defined as the normal patient volume group, were on average 46.7 years of age, 59.1% female, 81.4% Black, and presenting with a mean triage acuity of 2.293 on a 4 point scale. Lab tests were ordered on average for 62.3% of registered patients, X-rays for 40.8% of patients and CT scans for 20.9% of patients. 25.4% of patients admitted, 65.2% discharged and 5.7% of patients left without being seen. White and Hispanic patients percents dropped in the surge group versus normal volume group (7.3% versus 6.9% p⫽0.01, 3.1% versus 2.8% p⫽0.01, respective) with other demographics remaining stable. The proportion of lab tests ordered as a percentage of total patients on that day also dropped (58.6% versus 57.4%, p⫽0.002), while X-rays and CT scans remained stable (38.4% versus 37.9% p⫽0.081 and 19.7% versus 19.3% p⫽0.11). Disposition profiles also changed, with a decrease in proportion of hospital admissions and discharges (25.4% versus 24.5% p⫽0.0008, 65.2% versus 63.5% p⫽0 respectively) and a rise in patients who left without being seen: (5.7% versus 8.2% p⫽0). These results were also reflected when patient volume was compared as two standard deviations around the mean, as well as when data was treated on a continuous scale. Regression analysis of deviance from the mean over the 1095 days of data yielded a remarkably cyclic variation with one outlier that was excluded from subsequent analyses.
Volume , . : September
Conclusion: In our day-to-day comparison of low, medium and high patient volume days, triage acuity remained markedly stable (2.297 versus 2.293 versus 2.307 respectively). It would thus appear from this and age/sex demographics that the population of patients constituting day to day fluctuations of sometimes over 100 patients are not intrinsically different than the general ED population from a triage standpoint.
263
Prevalence of Methicillin Resistant Staphylococcus aureus In Out-of-Hospital Health Care Providers
Blue R, Whittle JS, Thundiyil JG, Silvestri S, Ralls G, Sirotkin L, Ladde J, Weber K, Giordano P/Orlando Health, Orlando, FL
Study Objective: The Centers for Disease Control and Prevention estimates that approximately 1% of the general population is colonized by methicillin resistant Staphylococcus aureus (MRSA). However, studies have suggested that as many as 30% of health care workers and 16% of emergency department staff are colonized. There is no published data describing the colonization rates of out-of-hospital health care providers. This study sought to determine the prevalence of MRSA colonization in EMS personnel. Methods: This study was conducted at an urban tertiary referral level 1 trauma center emergency department which receives approximately 60 EMS transports per day. The study population consisted of a convenience sample of EMS personnel transporting patients to the facility, belonging to any of 14 regional EMS agencies. Subjects were consecutively enrolled on a voluntary basis upon arrival to the emergency department over a 3-day period. After receiving instructions, subjects used standard Dacron swabs to culture their nares under the supervision of a researcher. Swabs were plated onto BBL CHROMagar MRSA plates (Becton Dickinson) and growth was recorded at 24 and 48 hours. Subjects also completed a survey regarding demographic factors, occupational factors and potential risk factors for MRSA exposure. Data was evaluated using descriptive statistics and chi-squared and zstatistics to compare the MRSA prevalence rate of our sample population to previously published health care provider and emergency department worker prevalence rates. Further, we compared the EMS workers with positive cultures to those without to evaluate for occupational risk factors. Results: 100 subjects from 7 different EMS agencies were enrolled. Mean age was 31.9 years and 78% of subjects were male. Overall, 17% (95%CI 9.7-24.4%) of subjects had positive MRSA cultures. 13 cultures were positive at 24 hours, 4 were positive at 48 hours. Univariate analysis of multiple potential risk factors was performed. None of the variables including sex, transport type (interfacility v. emergency response), hours worked per week, frequency of patient contact, history of previously drained abscess, EMS agency, level of training, and showering at the workplace were significantly associated with MRSA colonization. Conclusion: This is the largest study to date to assess the prevalence of MRSA in EMS personnel. In this study, the MRSA prevalence in EMS personnel, 17%, is comparable to that of ED personnel (16%) and higher than that seen in the general population (1%). These data suggest that EMS personnel share a similar occupational risk for MRSA colonization as other health care providers.
264
EMS to ED Handoffs: A Prospective Observational Analysis
Meisel ZF, Peacock N, Mechem CC/University of Pennsylvania, Philadelphia, PA
Study Objectives: Patient handoffs are known to be opportunities for medical error. Little is known about the form and character of out-of-hospital-to-emergency department (ED) handoffs. We conducted a prospective observational study of outof-hospital-ED handoffs at an urban academic medical center. We sought to characterize the situational structure (SS) and informational content (IC) of the real time handoff. We hypothesized that the information conveyed at these transitions would vary as a function of patient, provider, and situational factors. We also sought to specifically characterize handoffs for patients with documented markedly abnormal out-of-hospital vital signs as these patients may be at highest risk for adverse events due to communication failures at the transition of care. Methods: Trained EMT and physician observers were placed at a busy urban ED in shifts varying in time of day and day of week, over eighty cumulative hours. Nontrauma patients were tracked from EMS arrival to departure. All interactions between out-of-hospital providers and ED personnel were recorded on a standardized form, and subsequently compared to out-of-hospital records, all of which were unavailable at the time of the handoff. SS variables included time of day, location in ED, duration, physician presence, EMS provider type, and ED crowding score. IC
Annals of Emergency Medicine S87
262
Quantification of Daily Surge Volume In the Emergency Department
Milzman DP, Soe-Lin H, Orr J, Elliot J/Georgetown U School of Medicine/ Georgetown WHC EM Residency, Washington, MD
Study Objective: Proposals to deal with surges in patient volume have ranged from disease-specific triage management protocols to disaster-specific medical response protocols. Attempts to conceptually qualify what constitutes a surge volume, and daily fluctuations in patient volume that do not overwhelm emergency department capacity, can be categorized as a daily surge. However, to date no studies have attempted to empirically quantify what volume of patients constitutes a true surge. The current study examines the effect of daily fluctuations in patient volume retrospectively over a three-year period. Methods: Using Azyxxi, the electronic medical records system developed by Smith and Feied (Microsoft, Redmond WA), a retrospective database analysis was conducted for all patients entering the emergency department of a 900-bed tertiary care level 1 trauma center with approximately 85,000 ED visits per year, over a threeyear period from 2005 to 2008. Age, sex, race, and disposition demographics were collected on a per day basis, as well as labs, x-rays, and CT scans ordered on that day. Over the 1095 days of collected data, patient subcohorts of low and high volume days were constructed based on either standard deviations below and above the mean, respectively. Percentage of tests ordered as well as disposition profiles between these groups were subsequently compared via two-sample Wilcoxon rank-sum (MannWhitney) using STATA SE 10.0 statistical software (StataCorp, College Station TX). Results: Over 1095 days of collected daily patient volume, the mean number of patients was 210 with a standard deviation of 40. Patients within one standard deviation of the mean, defined as the normal patient volume group, were on average 46.7 years of age, 59.1% female, 81.4% Black, and presenting with a mean triage acuity of 2.293 on a 4 point scale. Lab tests were ordered on average for 62.3% of registered patients, X-rays for 40.8% of patients and CT scans for 20.9% of patients. 25.4% of patients admitted, 65.2% discharged and 5.7% of patients left without being seen. White and Hispanic patients percents dropped in the surge group versus normal volume group (7.3% versus 6.9% p⫽0.01, 3.1% versus 2.8% p⫽0.01, respective) with other demographics remaining stable. The proportion of lab tests ordered as a percentage of total patients on that day also dropped (58.6% versus 57.4%, p⫽0.002), while X-rays and CT scans remained stable (38.4% versus 37.9% p⫽0.081 and 19.7% versus 19.3% p⫽0.11). Disposition profiles also changed, with a decrease in proportion of hospital admissions and discharges (25.4% versus 24.5% p⫽0.0008, 65.2% versus 63.5% p⫽0 respectively) and a rise in patients who left without being seen: (5.7% versus 8.2% p⫽0). These results were also reflected when patient volume was compared as two standard deviations around the mean, as well as when data was treated on a continuous scale. Regression analysis of deviance from the mean over the 1095 days of data yielded a remarkably cyclic variation with one outlier that was excluded from subsequent analyses.
Volume , . : September
Conclusion: In our day-to-day comparison of low, medium and high patient volume days, triage acuity remained markedly stable (2.297 versus 2.293 versus 2.307 respectively). It would thus appear from this and age/sex demographics that the population of patients constituting day to day fluctuations of sometimes over 100 patients are not intrinsically different than the general ED population from a triage standpoint.
263
Prevalence of Methicillin Resistant Staphylococcus aureus In Out-of-Hospital Health Care Providers
Blue R, Whittle JS, Thundiyil JG, Silvestri S, Ralls G, Sirotkin L, Ladde J, Weber K, Giordano P/Orlando Health, Orlando, FL
Study Objective: The Centers for Disease Control and Prevention estimates that approximately 1% of the general population is colonized by methicillin resistant Staphylococcus aureus (MRSA). However, studies have suggested that as many as 30% of health care workers and 16% of emergency department staff are colonized. There is no published data describing the colonization rates of out-of-hospital health care providers. This study sought to determine the prevalence of MRSA colonization in EMS personnel. Methods: This study was conducted at an urban tertiary referral level 1 trauma center emergency department which receives approximately 60 EMS transports per day. The study population consisted of a convenience sample of EMS personnel transporting patients to the facility, belonging to any of 14 regional EMS agencies. Subjects were consecutively enrolled on a voluntary basis upon arrival to the emergency department over a 3-day period. After receiving instructions, subjects used standard Dacron swabs to culture their nares under the supervision of a researcher. Swabs were plated onto BBL CHROMagar MRSA plates (Becton Dickinson) and growth was recorded at 24 and 48 hours. Subjects also completed a survey regarding demographic factors, occupational factors and potential risk factors for MRSA exposure. Data was evaluated using descriptive statistics and chi-squared and zstatistics to compare the MRSA prevalence rate of our sample population to previously published health care provider and emergency department worker prevalence rates. Further, we compared the EMS workers with positive cultures to those without to evaluate for occupational risk factors. Results: 100 subjects from 7 different EMS agencies were enrolled. Mean age was 31.9 years and 78% of subjects were male. Overall, 17% (95%CI 9.7-24.4%) of subjects had positive MRSA cultures. 13 cultures were positive at 24 hours, 4 were positive at 48 hours. Univariate analysis of multiple potential risk factors was performed. None of the variables including sex, transport type (interfacility v. emergency response), hours worked per week, frequency of patient contact, history of previously drained abscess, EMS agency, level of training, and showering at the workplace were significantly associated with MRSA colonization. Conclusion: This is the largest study to date to assess the prevalence of MRSA in EMS personnel. In this study, the MRSA prevalence in EMS personnel, 17%, is comparable to that of ED personnel (16%) and higher than that seen in the general population (1%). These data suggest that EMS personnel share a similar occupational risk for MRSA colonization as other health care providers.
264
EMS to ED Handoffs: A Prospective Observational Analysis
Meisel ZF, Peacock N, Mechem CC/University of Pennsylvania, Philadelphia, PA
Study Objectives: Patient handoffs are known to be opportunities for medical error. Little is known about the form and character of out-of-hospital-to-emergency department (ED) handoffs. We conducted a prospective observational study of outof-hospital-ED handoffs at an urban academic medical center. We sought to characterize the situational structure (SS) and informational content (IC) of the real time handoff. We hypothesized that the information conveyed at these transitions would vary as a function of patient, provider, and situational factors. We also sought to specifically characterize handoffs for patients with documented markedly abnormal out-of-hospital vital signs as these patients may be at highest risk for adverse events due to communication failures at the transition of care. Methods: Trained EMT and physician observers were placed at a busy urban ED in shifts varying in time of day and day of week, over eighty cumulative hours. Nontrauma patients were tracked from EMS arrival to departure. All interactions between out-of-hospital providers and ED personnel were recorded on a standardized form, and subsequently compared to out-of-hospital records, all of which were unavailable at the time of the handoff. SS variables included time of day, location in ED, duration, physician presence, EMS provider type, and ED crowding score. IC
Annals of Emergency Medicine S87